I'm a former banker turned venture capitalist, musician and over-committed volunteer. My firm, T2 Venture Creation, is dedicated to building great start up companies, and leading the buildout of the ecosystems that cause them. My role is Chief Strategy Officer. I am deeply interested in how we learn about ourselves and the world, and how that learning translates into innovative business and educational leadership. I have an abiding curiosity about English Literature, physics, computing, and the Humanities in general. I also serve as Executive-in-Residence for the College of Liberal Arts and Sciences at UNC Charlotte, where I indulge my interest in pedagogy, graduate studies in Early Modern Literature, and opining. And I'm a singer-songwriter wannabe.

Innovation In Advanced Care Is The Key To Healthcare Reform

“That we must all die, we always knew; I wish I had remembered it sooner.” – Samuel Johnson: Letter to Joshua Reynolds

This interview is the third in a series with Dr. Brad Stuart, a physician and leader in advanced care innovation. In the first interview – here – we discussed the current state of health care in the U. S. and how we might approach innovation in the overall health care system. In the second – here – we discussed the critical role that accountable care can play in driving innovation in delivery, payment and quality. In this third installment, we are talking about the outsized role that advanced care plays today from both a cost and patient experience perspective, and how we might change our approach to advanced care.

Henry: You have frequently talked about advanced care as the most important area of health care for the future. Why is that?

Dr. Stuart: Well, let’s start by defining “advanced care.” When we talk about advanced care we are talking about people with one or more chronic diagnoses, who are resistant to treatment and who are experiencing declining function and poor prospects for recovery. People with these kinds of illness are entering a gray zone between treatable and terminal illness. I think we are called to do two things in this world: We absolutely must create a more compassionate and effective approach to delivering care to those who are in this stage of life, and we must begin to understand and better manage the cost of advanced care.

Henry: That makes sense, of course. But how do you manage to talk about “costs” when you are dealing with human suffering and personal tragedy? Doesn’t that come across as being a little cold-hearted?

Dr. Stuart: You are exactly right. The advanced care conversation is a difficult one. Think about this: Advanced illness is not a sexy conversation topic. The quickest way for me to clear the room at a party is to tell people what I do for work. Advanced illness is fraught with emotional baggage. It’s very hard for people to talk about. But, ironically, it’s this very difficulty that makes it prime territory for innovation.

Henry: Before we talk about innovation, talk a little about just how big this advanced care challenge is.

Dr. Stuart: It’s probably bigger than you think, both in terms of human impact and in terms of cost. Let me just hit the high points. Over 25.0 percent of the entire Medicare budget is spent in the last year of patients’ lives. Over 30.0% of this is concentrated in the last month prior to death, and 80.0% of that is in the hospital. In the Medicare population, 5.0% of all beneficiaries account for half of the costs. And a very large portion of this 5.0% is made up of people with advanced illness who are cycling in and out of the hospital. So, in the world of advanced care, we have a substantial increase in expenditures, an increasing burden on Medicare, and a less-than-ideal patient experience. That seems to be an obvious place to start making dramatic changes.

Improving the delivery of advanced care is grounded in a focus on at-home care, rather than frequent hospitalizations.

Henry: OK, now I think we’re ready to start talking about innovation! What kind of changes do you see coming in advanced care, and how are those changes going to affect patients?

Dr. Stuart: Let me start where we should all start. We should understand that in advanced care, we are talking about helping people, not patients, get the most out of every minute of life, to support the incredible human capacity to adapt to even the hardest things, to take advantage of the American desire for autonomy. Advanced illness places terrible burdens on people afflicted with it. But even the frailest, sickest senior in a bare-bones slum apartment is not thinking of herself as “sick” or “dying”; she is thinking about living. Our job in advanced care is to support her living needs, at home and in her community.

Henry: OK. That sounds great and right and good. But how do we do this and at the same time begin to deal with a cost model that is spiraling out of control? Can we afford these idealistic goals?

Dr. Stuart: This is the great part about innovations in advanced care. We can both improve the patient’s experience and begin to reduce costs significantly, at the same time. And all that’s really required is a change in perspective, a paradigm shift. There are just a few conceptual barriers between us and significant innovation, and those barriers are all in how we think about advanced care, not what we do in advanced care.

Henry: There’s that paradigm shift thing again. So, you believe that we just need to change how we think about advanced care in order to drive the changes we need?

Dr. Stuart: Very much so. Let’s start with the first barrier. The real problems in advanced illness aren’t medical; they are problems with life. For example, research shows that 75.0% of heart failure readmissions are due to non-medical factors. People lose their prescriptions or can’t afford to get them filled. Others have no idea they should cut back on their salt intake or they’ll get overloaded with fluid. Still others have no one to help them manage their affairs. When their heart failure gets worse and they lose their breath at 4 AM, there’s nowhere to go but back to the ER, and hospital admission follows. An effective, innovative advanced care approach can avoid that by anticipating problems, providing support, and bringing medical treatment to people where they live. Obviously, it’s better for everyone if that crisis never happens.

Henry: This sounds to me like we are talking about the hospital as the problem, that instead of hospitals, we should have more home-based care.

Most advanced care patients prefer to be supported at home, not at the hospital

Dr. Stuart: Yes, but let’s be very clear here. It’s not the hospital that’s the problem; the problem is people with chronic or advanced illness going there when they really don’t need to and don’t really want to. It’s going to the hospital at a stage of life when that is precisely the thing you should not be doing.

Henry: But still, everyone does go to the hospital. Why is that and what could we do about it?

Dr. Stuart: The problem here is simple. Many of our clinical and business models in health care are just upside down and the way we deal with advanced illness is more so than many other areas. Let’s look at repeat admissions to the hospital for advanced illness. Surveys show consistently that over 80.0% of seriously ill people would rather be at home near the end of life, not in the hospital. So, a big part of dealing with advanced illness in a more cost-effective and compassionate way is developing models that deliver at-home care, and that help those with chronic illnesses stay out of the hospital and out of recurring treatment cycles. Doing this can have a major impact on the quality and cost of care for the whole population: Quality, because these people want and need support where they live, so programs that supply this support automatically increase their well-being and quality of life. Cost, because our data show that the great majority of people with advanced illness will decide not to go back to the hospital if they are given the means to avoid it. On top of that, there are a couple of bonuses. First, Medicare saves a lot of dollars. Second, ill people have free choice.

Henry: So, we save money, the ill person’s well-being and quality of life is preserved and the choice becomes the individual’s – so no “death panels!” With that in mind, any closing thoughts on advanced care?

Dr. Stuart: Just this. We do not ever have to sacrifice quality of care in service to reducing costs. I strongly believe that real innovation in healthcare delivers a better experience at lower cost — both at the same time. In the end, I think we will find innovation and improvement in the simple notion that healthcare is something that is person to person, human to human, not just a professional fighting disease. I think we have lost that to some degree in modern healthcare, and we need to get it back.

Dr. Brad Stuart is one of those practitioners on the cutting edge of reform. He has more than thirty five years of experience in internal medicine, palliative care and hospice, and is a nationally recognized innovator in healthcare. He has devoted a lifetime of work to improving clinical and economic outcomes in medicine, by focusing on “dignity, choice and responsibility.” He is co-founder and CEO of ACIStrategies. He will be sharing his thoughts on healthcare issues at the upcoming Global Innovation Summit in San Jose, California.

Henry Doss is a student, musician, venture capitalist and volunteer in higher education. His firm, T2VC, builds startups and the ecosystems that grow them. His university is UNC Charlotte.

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